Provider Demographics
NPI:1467175125
Name:WELLS, BERNARDINE
Entity Type:Individual
Prefix:
First Name:BERNARDINE
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 BRIDFORD PKWY APT 7J
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-2677
Mailing Address - Country:US
Mailing Address - Phone:617-966-6229
Mailing Address - Fax:
Practice Address - Street 1:1505 BRIDFORD PKWY APT 7J
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-2677
Practice Address - Country:US
Practice Address - Phone:617-966-6229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701011809101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health